Rethinking Hypothyroidism by Dr. Antonio Bianco — A Critical Book Review

Episode 40: Rethinking Hypothyroidism by Dr. Antonio Bianco — A Critical Book Review

In this special episode of Beyond the Thyroid, Dr. Dana Gibbs takes a deep dive into one of the most important thyroid books published in the last decade: "Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do" by Dr. Antonio Bianco.

Offering both a physician’s perspective and a patient-centered lens, Dr. Gibbs unpacks the history, politics, and scientific debate behind standard thyroid care — and why so many patients still feel unwell despite “normal” labs. She highlights Dr. Bianco’s key insights, explores where she agrees or disagrees, and explains why this book matters for anyone who has ever felt dismissed by conventional endocrinology.

This episode also features listener questions, including how to safely adjust thyroid medication, plus resources for both patients and physicians available on Dr. Gibbs’ website.

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Episode Highlights

00:00 – Introduction and Episode Overview
00:58 – Host Introduction and Personal Journey
02:14 – Fan Mail and Listener Questions
04:17 – Introducing Rethinking Hypothyroidism
06:36 – Key Insights from the Book
09:32 – Challenges in Modern Thyroid Treatment
13:06 – Dr. Bianco’s Recommendations & Guidelines
19:52 – Critique and Final Thoughts
24:58 – Conclusion and Call to Action

Whether you're new to thyroid disease or a longtime advocate for better care, this episode will challenge the status quo and empower you with deeper understanding.

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✉️ Email Dr. Gibbs at drgibbs@DanaGibbsMD.com or visit https://www.danagibbsmd.com/ for more information.


Thank you so much for listening! Tune in on the next episode.


The medical information provided in this episode is intended for informational purposes only and should not be construed as medical advice. Always consult a qualified healthcare provider regarding any medical questions or concerns.

Transcript

dana-gibbs-md--she-_1_12-01-2025_111529: 0:00

Welcome to episode 40. Hi everybody. Today's episode is gonna be a bit different because today I'm gonna do my first ever book review. So this book is from 2022, but I only recently heard about it when Peter Atia recently interviewed the author Antonio Bianco on his podcast. The book is Rethinking Hypothyroidism. Why treatment must change and what patients can do. So today I'm gonna break this book down to let you know just exactly what it's all about and why I think it's important for patients. Unfortunately, the T-L-D-R version is that there's not a lot of concrete advice in here for you except to keep looking for a doctor who will actually listen to you. If you aren't feeling your best as a review of the current state of thyroid in the US though, it's much better. Maybe your endocrinologist should read it. Let's get started.

1:09

You're listening to the Beyond the Thyroid podcast. I'm your host, Dr. Dana Gibbs. I'm an ENT surgeon and hormone specialist. For years, I struggled with my own unrecognized thyroid problems before and even after I was regularly performing thyroid surgeries. Then, one day, I learned something that turned my health around and opened my eyes to the limits of mainstream medicine in treating more subtle thyroid abnormalities. I spent the next 20 years fine tuning my hormone expertise in disorders like Hashimoto's disease, perimenopause, and stress related illness. Come join me as I share this new approach to hormones that empowers you to take control of your own thyroid and hormone imbalances. Let's dive in.

dana-gibbs-md--she-_3_12-01-2025_112057: 2:04

Hello and welcome back to Beyond the Thyroid. I'm your host, Dr. Dana Gibbs. If you're new here, welcome, happy to have you. And today is gonna be a book review. But before I do that, I want to answer some fan mail'cause this is really exciting for me to get fan mail. And this is from Sarah in Harwinton, Connecticut, and she says,"hello, Dr. Gibbs. Thank you for your informative podcast series. I have shared them with the doctor that's currently monitoring my thyroid status, and we are excited to put some of your theories in place. Mainly the twice a day dosing that you recommend with testing at six hours after the morning dose and utilizing the total T3 RT3 ratio result." One question that she asked is"if I had come across in listening to the episodes, how soon after a dose change is it recommended to recheck labs? We're using the common recommendations now of no less than six weeks and up to three months. How does that align with your thinking?" Thank you so much for your mail and your comments, Sarah. The answer to that is when you are rapidly changing your thyroid dose, four to six weeks is probably. A good answer for waiting to test once you're on a stable dose. However, if all you're doing is changing your dose from all of it at once to half in the morning and half in the evening, you should start seeing results within two to three weeks. So I don't think you need to wait. Certainly three months. I think you could probably do your test within four weeks of making that change. So hopefully that helps if your doc has more questions. On my website, there are free webinars for physicians that she could watch in the for physicians section. That's www.danagibbsmd.com. So hope that answers the question. All right, on to the episode. All right, so this book, it's called Rethinking Hypothyroidism, why Treatment Must Change and What Patients Can Do. I have to tell you that this perspective matters because it was written by a highly respected, mainstream endocrinologist, and he's not just the one following the policies, he's the one who's making them. Dr. Bianco is the dean of a medical school. He runs a prestigious research lab at yet a different high prestige university, and he's a former president of the US body that sets guidelines for thyroid treatment, the American Thyroid Association. And I will tell you, this book was a pretty entertaining read for somebody like me. I spend a lot of my waking hours geeking out about thyroid. Reading papers on the internet. So this book confirmed from an insider's view. Some sorted stories that I had heard about the history of thyroid treatment. It also confirmed that my understanding of the science of hypothyroidism is pretty up to date. Keep in mind where I come from, so I have both the physicians' and the patient's point of view to reading this book, but my doctor perspective is not that of somebody who started my career in the culture of endocrinology being indoctrinated. So maybe you remember my story. I was a thyroid surgeon before I even knew that I was a thyroid patient. I watched my postoperative thyroid surgery patients lose their energy, their hair, and their waistlines. While their endocrinologists insisted that everything was fine, I really became convinced that there was way more to thyroid than TSH though when I went to a conference and saw a list of the symptoms of most of which I had and. You know, my own own TSH was normal, but I went to my doc and I asked to try armored thyroid and my symptoms disappeared almost completely within. Days to weeks. So I was convinced, okay, there's more to thyroid than TSH and I started learning. Why does this book matter? Well, I came into reading the book with really high hopes because Dr. Bianco's name is on many of the research papers that I read about cutting edge thyroid research. So when Dr. Bianco writes about the internal politics, the scientific blind spots, and the enormous inertia in the institution of thyroid care and the endocrinologist. I recognize this landscape that he's describing because I fight it kind of every day. He sees himself as a catalyst for change and I really do hope that's gonna turn out to be true. But changing the course of a hundred year old medical society with 50 years of TSH only dogma behind it is a bit like trying to turn an ocean liner with a tugboat. It's a really slow and tricky process. There is so much valid information in this book though, and I wanna give credit where credit is due. Science first. Active T3 thyroid hormone is mostly made in our bodies biotinidase enzymes, and he knows as much as anyone in the world about how all the enzymes work. And as a matter of fact, he and his colleagues are doing a lot of the research into this important topic, and he explains this complicated subject in a way that most primary care doctors, if not patients, are gonna understand. He clearly describes how hypothyroid patients who are given T4 have less good outcomes than normal people who don't need to take thyroid medicine. Double mortality, higher weight, more cardiovascular disease, higher blood lipid levels, more statin use. Mental capacity, less. Quality of life, lower, and he knows why. He even said it on Peter Atia's podcast recently, about 3 weeks ago now, when I'm recording this, if not in the book, and it's because taking T4 for most people actually lowers the amount of the circulating active hormone T3 that they have. He explains in detail how 20% of people who are given T4 medications don't improve despite having a normal TSH on their treatment. And at the very end, he even proposed a name for this condition, or a syndrome, he called it. He called it SORSHOT, which stands for syndrome of residual symptoms of hypothyroidism on T4. He knows that giving this cohort of people who don't do well T3 improves their lipids, improves their weight, and improves their quality of life, and he encourages doctors to consider giving T3 to patients whose symptoms are not resolved with T4. These elements are a huge step for somebody who's writing from inside the system. Now, a large portion of this book is a deep dive into the whole history of thyroid treatment in fairly excruciating detail. He includes who discovered what, and he seems to know them all personally, but without apology, he reveals the darker story of the politics and the outsize influence that the pharmaceutical industry has had on today's thyroid prescribing practice. The focus of current modern research and the outcomes. He matter-of-factly exposes what ought to really shock him, the baseless and harmful suppression of a very good treatment for hypothyroidism. Desiccated thyroid was not abandoned because it was unsafe or ineffective. It was abandoned because synthroid's manufacturer wanted market dominance and set out to make that happen. There was no superiority study. There was no outcomes data for Synthroid. There was no proof of benefit with Synthroid. But there was money, lots of it, and there were doctors who were recruited, groomed, and promoted for supporting this ship. This is not my interpretation, this is the history Dr. Bianco lays out in his book. He also talked about the birth of the dogma of thyroid treatment. He didn't spend a whole lot of time on the history of the early use of the TSH test or its validation, but he did point out the origins back in the seventies of. Some other medical dogmas that were codified and persisted into the present. The first one of these is that a normal TSH automatically equals optimal thyroid treatment. Before the mid seventies when TSH was new, many writers pointed out that not everyone was feeling well with a normal TSH, but they were ignored once it was known that T4 does convert to T3. Even in people who have had their thyroids removed, it was also assumed that this always happened in always inadequate amounts in everyone, even if they only tip T4. This was never proven by research, never. So these two ideas really formed the basis of the first ATA guidelines in 1995, having become set in stone over the prior 20 years. And then the third one, this one, that natural thyroid is not recommended. That's language that's written, and that's a quote in the guidelines. Even in the modern ones. That language started out in the 70s as a mild questioning of the superiority of desiccated thyroid products which contained T3 because of lack of dose standardization at a time. So the language kind of got stronger over time despite the lack of proof that desiccated thyroid was inferior. Even the improved potency essays that were instituted by the FDA in the 1980s could not save it, nor could the multitudes of patients who claim that they felt worse after being switched to levothyroxine. So by the time the 95 guidelines came out, this belief was also set in stone: natural thyroid is not good medicine. Anyway. Dr. Bianco then went on to discuss what the latest guidelines are that he helped write. These are now over 10 years old as of 2025, and he used the few newer studies that are now out there to advocate for language that opens the door to the possibility of treatment with T3 for select patients. He also advocated listening to the patients. Gasp, right? Because up till then, thyroid patients who complained that their symptoms weren't resolved were sent to the psychiatrist. Good grief. Anyway, let me tell you why I think this is a really good thing. So this document, the guidelines is published by the very organization that Bianco was the president of, and unofficially it sets the standard of care by which all doctors who prescribe thyroid medicine are judged and it even has language in there that castigates doctors who dare to go outside the guidelines. Medical students and young residents are now indoctrinated with a very abbreviated summary of these best practices from year one of their training. So think about the environment of medicine today. Doctors in fear of lawsuits, censure by medical boards who can take your license away. Hospital peer review groups who can get you fired. The insurance companies who withhold reimbursement of the not recommended medication because it fails to meet the standard of care. Is it any wonder? Most doctors won't treat outside those main recommendations? The very doctors who have been indoctrinated in this way are then asked to update the guidelines, so it's actually quite shocking that Dr. Bianco was willing to stick his neck out in this way. So the newest guidelines from 2014 still say, test TSH may be test T4 and treat with levothyroxine almost always. T3 is still considered innovative therapy, although the guidelines do mention that some patients don't do well with T4 alone, and that about 3% of endocrinologists are using T3 therapy. Remember this was 10 years ago. But it's considered"innovative therapy" and I'm using air quotes here, and by innovative they do not mean good. Except that for 20% of us, T4 doesn't work. And for even more than that, it fails to normalize the weight, the cognition, and the metabolic markers and the heart disease risk, even in patients who feel okay. So for doctors, what are his new recommendations and how are we supposed to interpret them to best help our patients? Well, first of all, he admits that he was wrong to discount his patient's symptoms for all those years when they weren't feeling back to normal on T4 therapy, and he calls for all doctors to listen to their patients to help decide who might be a candidate for T3. This is a huge step because for 50 years now, and despite nearly all large clinical studies showing that T4 treatment fails to uniformly normalize T3, the patient's symptoms have not mattered as long as that TSH is in that range. As a matter of fact, the guidelines still contain recommendations about psychiatric referrals when T4 fails to improve symptoms of people who take thyroid medicine, he clearly states that some people do better on T3 and that the way to figure it out is to listen. He also advocates a trial of added T3 for people with hypothyroidism who still don't feel well, but he's really not forthcoming about how this is to be done. There are mixed messages about T3 dosing. On the podcast with Peter Atia, he cites a study that showed a three and a half to one. T4 to T3 ratio given to patients achieved uniformly the best outcomes versus 2:1 or 5:1 or 6:1 or several other different formulations that were tried. Natural thyroid preparations are pretty close. They're 4:1. Slightly lower than the ideal that they got the best outcomes with. But in the book, he then goes back and he recommends 10:1 or even 15:1, which is far less T3 than the best outcomes in that study. He notes T3 is short acting but does not make divided dosing recommendations. He acknowledges that high T4 reduces T3 production, but does not discuss how to safely lower t4 in practice. There's also in this book, a lot of fear-based caution about using T3. So he defers to the guidelines, which cite the theoretical dangers from T3 spikes. This despite decades of no data that shows actual harm with T3 is carefully dosed and monitored. He suggests we continue to wait for slower, long-acting safer formulations of T3, which are in research right now. Meanwhile, T4 overtreatment is linked to bone loss and untreated hypothyroidism also accelerates bone loss and heart disease. Why do he and the academic thyroid world delay providing recommendations? Well. I am not sure, but here's a clue. So there is a new heart effect sparing supposedly safer T3 agonist medication that the FDA approved this year. Its brand name is Rezdiffra and it costs over$4,000 a month or$49,000 a year. So are other drugs that get new FDA approval gonna be more economically feasible than this? We hope so, but this does nothing for ordinary Jane who really can't afford to spend$200 a month on one medication, let alone$4,000. So maybe you can guess what I think the answer to why we have to wait for long acting T3. Alright. There are some stuff that the book completely leaves out, and I think this is important because these omissions really do shape real world care. So the first one is, and the most important one, is the role of primary care physicians. Dr. Bianco never addresses that. Most thyroid patients in the US are not even being managed by endocrinologists at all. And here's the deal, community, endocrinologists in my city are actually dismissing their thyroid only patients. I don't know if this is happening around the country or not, but diabetes management has become far more financially lucrative lately because of charges for something called remote patient monitoring. So these thyroid patients are being dismissed and then they have to get their meds from their primary physician if they're not already. Primary care doctors with far less endocrine training and no access to the endocrine journals unless they sign up to be members of the endocrine society and far less time available to manage thyroid care amongst all their other priorities, may feel that they have to follow those guidelines which still don't help them decide who needs T3, let alone explain how to do it safely, even if they want to. Alright. It also leaves out much of any actionable advice for patients. So despite the subtitle, this book gives essentially no usable strategies to patients who are dealing with symptomatic hypothyroidism. Particularly if you're one of these people who's being told that everything is fine, when you know it isn't. His advice amounts to ask your doctor to give you a tiny amount of T3 and hope your doctor agrees. Accept TSH as the best test to monitor your thyroid treatment and patiently wait for long-acting T3 to be approved by the FDA and added to the guidelines. The other thing that it doesn't talk about is the reference ranges, there was really zero mention about the politics and controversies around the TSH reference range in particular, and how removal of people with evidence of autoimmune thyroiditis from the normal population sample actually brings the upper limit of normal down to between 2.5 and 3 instead of 4.5. But that is not being incorporated into the numbers in the major labs for normal TSH, the fact that relatively few patients with autoimmune thyroid disease fill well when their T3 is in the low half of the reference range, or that the T4 in the upper half of the reference range is also problematic because it causes hidden side effects like bone loss were not mentioned at all. On the podcast, he blamed the inaccuracy of the common T3 lab essay for it not being recognized by endocrinologists as a useful test. And in the book, he dismissed it altogether. When he was asked by Dr. Atia, he simply said, we don't test T3 and reverse T3. He declares this dead in the podcast and he didn't even mention it in the book. He ignores research that contradicts the position that reverse T3 has no meaningful function in the body. And this omission to me is pretty glaring. but here was the most disappointing part for me, for all of us whose TSH is still in the reference range, forget about it. You still don't have hypothyroidism according to the definition of Dr. Bianco and every mainstream endocrinologist out there, even with the problems with the TSH, which he didn't mention anyway. Oh, wait. Except for fertility specialists who treat when TSH gets above 2.5. So this failure, despite him spending 30 pages explaining to us all the complexity and the vulnerability in the system that delivers active T3 thyroid hormone to the tissues that need it, what could possibly be going wrong? Well, no answers here. For why a single pituitary hormone instead gets to define the entire thyroid system for all these folks. My final assessment, despite my criticisms, this book still matters, and I'm really glad he wrote it. It signals movement. It signals acknowledgement from within the academic endocrinology community that change is long overdue. Maybe it will soften the rigid grip of levothyroxine only treatment for some endocrinologists and hopefully even some primary care docs. The ship can turn, but it will happen faster if the people who are driving help steer. For the rest of us, we'll keep doing what actually works for our individual patients. More comprehensive testing, more critical interpretation of the test, and using our patients' outcomes as the guide to successful treatment. Alright, that's it for now. Thanks for listening. So if you are a physician and you wanna learn a more nuanced way to manage patients who appear hypothyroidism despite normal labs, you can visit my website, danagibbsmd.com to get on the interest list for the next round of the new endocrinology, which is an integrative hormone course for doctors by doctors who are interested in helping all their patients feel well, not just normalizing numbers. Y'all have a great afternoon and I'll talk to you again soon.

25:38

Thank you for listening to this episode of Beyond the Thyroid. If you found this information valuable, it would mean so much to me to take a few seconds and give the podcast a five star review. It helps other people who need this information find the show and it's really easy. Just search and click on the name of the show, Beyond the Thyroid, and scroll to the bottom to ratings and reviews. I truly do read and appreciate. Remember, when it comes to hormones, there will always be more to discover, so follow the show so you get the next episode as soon as it's released. And if you or someone you care about needs a caring doctor to help figure out how to heal hormone problems that other doctors have dismissed, check out my website at www. danagibbsmd. com. And if you're not a physician, please keep in mind, while I'm a doctor, I'm not your doctor. The content of this podcast is my opinion and it's for educational and entertainment purposes only. This is not meant to be individual medical advice and you should consult your own physician for any medical issues or diagnoses that you may have. I look forward to continuing this journey with you beyond the thyroid.